Angiosomes and wound care in the diabetic foot

Single-Incision Direct Lateral Approach Versus Dual-Incision Approach for Distal Tibial and Fibular Fractures

INTRODUCTION

Distal tibial and fibular fractures are typically the result of high-energy trauma. Open reduction and internal fixation (ORIF) are often used to reconstruct and reduce displaced fractures, especially intra-articular ones. These fractures can be addressed either by a dual-incision approach (medial approach for the distal tibia and lateral approach for the fibula) or by a single-incision direct lateral approach to fix both the tibia and fibula. The direct lateral approach avoids injury to the medial soft tissues. This study was conducted to compare the postoperative clinico-radiological and functional outcomes of the single-incision direct lateral approach and the dual-incision approach for distal tibial and fibular fractures.

MATERIALS AND METHODS

A prospective comparative cohort study of 40 patients was conducted. The patients were classified into two cohorts of 20 each based on the surgical approach: those who underwent a single-incision direct lateral approach and those who underwent a dual-incision approach for distal tibial and fibular fractures (procedure: ORIF with plating). The study was conducted from September 2022 to March 2024. A follow-up period of at least 12 months was carried out, comparing operative time, discharge time, and postoperative outcomes using the American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot score, ankle range of motion (ROM), Southampton wound score for wound healing, visual analog scale (VAS) pain score, and periodic radiographs at each follow-up. Complications were also studied.

RESULTS

The mean operative time was 95.06 ± 7.04 minutes for the single-incision approach and 109.89 ± 7.88 minutes for the dual-incision approach. The average blood loss was 202.41 ± 32.76 mL for the single-incision approach and 248.39 ± 28.18 mL for the dual-incision approach. The hospital stay was shorter in the direct lateral approach group, and the AOFAS score at 12 months was better in the direct lateral approach group (91.47 ± 2.55 for the single-incision approach vs. 83.33 ± 8.71 for the dual-incision approach). Postoperative wound healing was observed, and the Southampton wound score was compared. Overall, soft tissue complications were fewer in the direct lateral approach group. The postoperative VAS pain score was consistently lower in the single-incision direct lateral approach group, which also demonstrated better ankle ROM. The p-value was significant (<0.05) for these parameters. At the six-month follow-up, all patients exhibited clinical and radiographic healing and bone union, except for one case in the dual-incision group. A medial compound wound, treated by plastic surgery with flap cover intervention, was identified as one of the definitive indications for single-incision plating.

CONCLUSION

The single-incision approach was associated with better soft tissue healing, fewer wound complications, and superior ankle functional outcomes compared to the dual-incision approach.

Challenging the angiosome concept: Delineating peripheral arterial disease patterns in diabetic foot ulcers

OBJECTIVES

The angiosome concept has significantly impacted diabetic foot ulcer management by highlighting the vascular anatomy's role in wound healing. However, its clinical applicability and validity remain debated due to complexities in foot blood supply and ulcer location determination.

METHODS

A cross-sectional study was conducted on 84 individuals with diabetic foot ulcers undergoing lower limb angiography. Demographics, ulcer characteristics, and angiographic data were collected and analyzed using descriptive statistics and relevant tests.

RESULTS

Digital subtraction angiography assessed 89 limbs with diabetic foot ulcers; males comprised 54.8%, primarily type 2 diabetes (96.4%), averaging 64.36 ± 10.09 years. Of 129 angiosomes, angiosome 2 (40.3%) had the highest ulcer incidence. Posterior tibial artery (PTA) involvement was predominant (72.9%), while external iliac artery (EIA) and profunda femoris artery (PFA) were least affected (2.4% each). Posterior tibial artery showed 46.5% complete occlusion. Angiosome 2 correlated notably with anterior tibial artery (ATA), peroneal artery (CPA), and PTA, but categorizing angiosomes by supply patterns showed no significant artery correlation (p > .05).

CONCLUSIONS

The research indicates inconsistent support for below-the-knee artery involvement correlating with foot ulcer locations in angiosomes. While aiding vascular comprehension, the angiosome concept may not fully elucidate lower limb vascular complexities and ulcer genesis. Factors like collateral circulation should be noticed to understanding ulcer localization and severity, extending beyond angiosomal arterial supply.

Peripheral Blood Mononuclear Cells: A New Frontier in the Management of Patients with Diabetes and No-Option Critical Limb Ischaemia

The current study aimed to evaluate the effectiveness of peripheral blood mononuclear cell (PB-MNC) therapy as adjuvant treatment for patients with diabetic foot ulcers (DFUs) and no-option critical limb ischaemia (NO-CLI). The study is a prospective, noncontrolled, observational study including patients with neuro-ischaemic DFUs and NO-CLI who had unsuccessful revascularization below the ankle (BTA) and persistence of foot ischaemia defined by TcPO2 values less than 30 mmHg. All patients received three cycles of PB-MNC therapy administered through a "below-the-ankle approach" in the affected foot along the wound-related artery according to the angiosome theory. The primary outcome measures were healing, major amputation, and survival after 1 year of follow-up. The secondary outcome measures were the evaluation of tissue perfusion by TcPO2 and foot pain defined by the numerical rating scale (NRS). Fifty-five patients were included. They were aged >70 years old and the majority were male and affected by type 2 diabetes with a long diabetes duration (>20 years); the majority of DFUs were infected and nearly 90% were assessed as gangrene. Overall, 69.1% of patients healed and survived, 3.6% healed and deceased, 10.9% did not heal and deceased, and 16.4% had a major amputation. At baseline and after PB-MNC therapy, the TcPO2 values were 17 ± 11 and 41 ± 12 mmHg, respectively (p < 0.0001), while the pain values (NRS) were 6.8 ± 1.7 vs. 2.8 ± 1.7, respectively (p < 0.0001). Any adverse event was recorded during the PB-MNC therapy. Adjuvant PB-MNC therapy seems to promote good outcomes in patients with NO-CLI and neuro-ischaemic DFUs.

Presence of a patent pedal arch is the primary predictor of transmetatarsal amputation healing and limb salvage

OBJECTIVE

Transmetatarsal amputation (TMA) is a durable and important functional limb salvage option. We have presented our results in identifying the angiographic predictors of TMA healing using single-institution retrospective data.

METHODS

Consecutive patients within our institution who had undergone TMA and lower extremity arteriography from 2012 to 2020 were included. Patients whose TMA had healed were compared with those whose TMA had not healed. Using pre- and perioperative patient factors, in addition to the Global Limb Anatomic Staging System (GLASS) and evaluation of the tibial runoff vessels, multivariate analysis was used to define the predictors of TMA healing at 30 days and 1 year. For those patients who had undergone an intervention after TMA, including repeat interventions, the postintervention GLASS stage was calculated. All patients were followed up by the vascular surgeon using standard ultrasound surveillance and clinical examinations. Once the predictors had been identified, an analysis was performed to correlate the 30-day and 1-year limb salvage rates.

RESULTS

A total of 89 patients had met the inclusion criteria for the study period. No difference was found in the GLASS femoropopliteal or infrapopliteal stages for those with a healed TMA and those without. After multivariate regression analysis, the presence of a patent pedal arch vs a nonintact arch had a 5.5 greater odds of TMA healing at 30 days but not at 1 year. Additionally, the presence of a patent arch was strongly associated with limb salvage at both 30 days (86% vs 49%; P < .01) and 1 year (79% vs 49%; P < .01).

CONCLUSIONS

In the present series of patients who had undergone TMA and arteriography, with appropriate GLASS staging, we found patency of the pedal arch was a significant predictor of healing and limb salvage. The GLASS femoropopliteal and infrapopliteal stages did not predict for TMA healing.

Evaluation of the Angiosome Concept Using Near-Infrared Fluorescence Imaging with Indocyanine Green

BACKGROUND

The angiosome concept is defined as the anatomical territory of a source artery within all tissue layers. When applying this theory in vascular surgery, direct revascularization (DR) is preferred to achieve increased blood flow toward the targeted angiosome of the foot in patients with lower extremity arterial disease (LEAD). This study evaluates the applicability of the angiosome concept using quantified near-infrared (NIR) fluorescence imaging with indocyanine green (ICG).

METHODS

This study included patients undergoing an endovascular- or surgical revascularization of the leg between January 2019 and December 2021. Preinterventional and postinterventional ICG NIR fluorescence imaging was performed. Three angiosomes on the dorsum of the foot were determined: the posterior tibial artery (hallux), the anterior tibial artery (dorsum of the foot) and the combined angiosome (second to fifth digit). The angiosomes were classified from the electronic patient records and the degree of collateralization was classified based on preprocedural computed tomography angiography and/or X-ray angiography. Fluorescence intensity was quantified in all angiosomes. A subgroup analysis based on endovascular or surgical revascularized angiosomes, and within critical limb threatening ischemia (CLTI) patients was performed.

RESULTS

ICG NIR fluorescence measurements were obtained in 52 patients (54 limbs) including a total of 157 angiosomes (121 DR and 36 indirect revascularizations [IR]). A significant improvement of all perfusion parameters in both the directly and indirectly revascularized angiosomes was found (P-values between <0.001-0.007). Within the indirectly revascularized angiosomes, 90.6% of the scored collaterals were classified as significant. When comparing the percentual change in perfusion parameters between the directly and indirectly revascularized angiosomes, no significant difference was seen in all perfusion parameters (P-values between 0.253 and 0.881). Similar results were shown in the CLTI patients subgroup analysis, displaying a significant improvement of perfusion parameters in both the direct and indirect angiosome groups (P-values between <0.001 and 0.007), and no significant difference when comparing the percentual parameter improvement between both angiosome groups (P-values between 0.134 and 0.359). Furthermore, no significant differences were observed when comparing percentual changes of perfusion parameters in directly and indirectly revascularized angiosomes for both endovascular and surgical interventions (P-values between 0.053 and 0.899).

CONCLUSIONS

This study proves that both DR and IR of an angiosome leads to an improvement of perfusion. This suggests that interventional strategies should not only focus on creating in-line flow to the supplying angiosome. One can argue that the angiosome concept is not applicable in patients with LEAD.

Limb Salvage in Severe Diabetic Foot Infection

Severe diabetic foot infections (DFI) are both limb threatening and life threatening and associated with negative impact on health-related quality of life. Most severe DFIs require surgical intervention, and the goal of treatment should be preservation of limb function in addition to eradication of infection. Minor amputations are required in approximately 40% and major amputations in approximately 20% of patients. Significant risk factors for lower extremity amputation included male gender, smoking, previous amputation, osteomyelitis, peripheral artery disease, retinopathy, severe infections, gangrene, neuroischemic diabetic foot infections, leukocytosis, positive wound cultures, and isolation of gram-negative bacteria.

In Patients with Lower Extremity Burns and Osteomyelitis, Diabetes Mellitus Increases Amputation Rate

In this retrospective analysis, we investigated the rate of radiologically confirmed osteomyelitis, extremity amputation and healthcare utilization in both the diabetic and non-diabetic lower extremity burn populations to determine the impact of diabetes mellitus on these outcomes. The burn registry was used to identify all patients admitted to our tertiary burn center from 2014 to 2018. Only patients with lower extremity burns (foot and/or ankle) were included. Statistical analysis was performed using Student's t test, chi-squared test, and Fischer's exact test. Of the 315 patients identified, 103 had a known diagnosis of diabetes mellitus and 212 did not. Seventeen patients were found to have osteomyelitis within three months of the burn injury. Fifteen of these patients had a history of diabetes. Notably, when non-diabetics were diagnosed with osteomyelitis, significant differences were observed in both length of stay and cost in comparison to their counterparts without osteomyelitis (36 vs 9 days; p=0.0003; $226,289 vs $48,818, p=0.0001). Eleven patients required an amputation and 10 (90.9%) of these patients had comorbid diabetes and documented diabetic neuropathy. Compared to non-diabetics, the diabetic cohort demonstrated both a higher average length of stay (13.7 vs 9.2 days, p-value=0.0016) and hospitalization cost ($72,883 vs $50,500, p-value=0.0058). Our findings highlight that diabetic patients with lower extremity burns are more likely to develop osteomyelitis than their non-diabetic counterparts and when osteomyelitis is present, diabetic patients have an increased amputation rate. Further study is required to develop protocols to treat this population, with the specific goal of minimizing patient morbidity and optimizing healthcare utilization.

Level of Agreement Between Systematic Doppler Examination of the Lower Extremity and Diagnostic Angiography in the Setting of Peripheral Arterial Disease

BACKGROUND

The objective of this investigation was to determine the level of agreement between a systematic clinical Doppler examination of the foot and ankle and diagnostic peripheral angiography.

METHODS

The described Doppler examination technique attempted to determine the patency, quality, and direction of the flow through the dorsalis pedis artery, posterior tibial artery, terminal branches of the peroneal artery, and vascular arch of the foot. These results were then compared with angiographic distal run-off images as interpreted by a blinded vascular surgeon.

RESULTS

Levels of agreement with respect to artery patency/quality ranged from 64.0% to 84.0%. Sensitivity ranged from 53.8% to 84.2%, and specificity ranged from 64.7% to 91.7%. Agreement with respect to arterial flow direction ranged from 73.3% to 90.5%.

CONCLUSIONS

We interpret these results to indicate that this comprehensive physical examination technique of the arterial flow to the foot and ankle with a Doppler device might serve as a reasonable initial surrogate to diagnostic angiography in some patients with peripheral arterial disease.

Indirect Endovascular Revascularization via Collaterals: A New Classification to Predict Wound Healing and Limb Salvage

BACKGROUND

In the setting of chronic limb ischemia, lower extremity (LE) wounds require revascularization of source arteries for wound healing and limb salvage. Direct revascularization of the source artery is preferred but cannot always be performed. Our objective was to analyze the influence of arterial-arterial connections on clinical outcomes after angiosome-directed endovascular revascularization.

METHODS

Consecutive LE wounds in patients with isolated infra-popliteal disease revascularized endovascularly from 2012 to 2016 within a single center were retrospectively reviewed. Treatment was classified as direct revascularization (DR) if the source artery supplying the wound angiosome was treated, indirect revascularization via collaterals (IR-C) if the source artery angiosome was revascularized by another major artery via arterial connections, or indirect revascularization (IR) if direct revascularization of the source artery angiosome was not possible. Demographics, comorbidities, and patient outcomes were collected.

RESULTS

Of 105 patients with 106 LE wounds, there were 35, 38, and 33 patients in the DR, IR-C, and IR groups, respectively. The mean age was 65.8 years old (standard deviation (SD) 11.9) with 81 males (77.1%) and 24 females (22.9%). Average follow-up was 21.0 months (SD 14.0). Overall wound healing rates were 80.0%, 92.1%, and 63.6% for DR, IR-C, and IR, respectively (P = 0.009). Significant differences were found between all 3 group comparisons, DR versus IR-C (P = 0.010), DR versus IR (P = 0.013), IR-C versus IR (P = 0.008). Overall major amputation-free survival was 85.7%, 89.5%, and 69.7% in DR, IR-C, and IR groups, respectively, with statistically significant differences between the IR-C and IR groups (P = 0.036).

CONCLUSIONS

Treating diseased infra-popliteal arteries and improving blood flow via arterial-arterial connections as per the angiosome model improved wound healing and amputation-free survival in this cohort. Although DR is still the gold standard, revascularization using IR-C may give superior healing results even in highly comorbid patients. This offers an additional avenue for treatment, especially when DR is not possible.

An Approach to Managing Midfoot Charcot Deformities

We present an approach to managing complex deformities in Charcot neuroarthropathy that typically present around the midfoot. This approach follows a stepwise progression from prevention, early detection, nonoperative through to operative management. It centers on multidisciplinary care with input from diabetologists, orthotists, plaster technicians, physiotherapists, orthopedic, vascular, and/or plastic surgeons. We discuss the timing of surgery with regard to Eichenholtz stage of disease and trends toward early surgical intervention. We review traditional and new surgical concepts. We evaluate the role of limited interventions. We aim to provide a template for deciding where future research priorities should be directed.

The role of reconstructive microsurgery in treating lower-extremity chronic wounds

Frequently considered chronic wounds for reconstruction are wounds lacking healing progress despite good wound care. And those needing microsurgical reconstruction are chronic wounds that are unable to close by local flap or skin grafts, wounds with exposed vital structure such as tendon and bones, and wounds that have prolonged infections such as osteomyelitis and skin necrosis. The reconstruction for soft tissue defects not only aims to provide coverage but to restore function and acceptable form as well. Wound preparation prior to microsurgical reconstruction consists of improving or restoring vascular supply, stabilising skeletal structures, and obtaining clinically clean wounds. Microsurgery is a surgical discipline that combines magnification with a advanced microscope, specialised precision tools, and various operating techniques. Thus microsurgery allows flap to be transferred far from the donor site restoring form and function to areas of the body that have lost skin, fat, muscle movement, and/or skeletal support. Microsurgery has expanded reconstructive surgery's elements and strategies and is still evolving. Along with the multidisciplinary approach and good principle of wound care, the repair and restoration strategies using microsurgery have widened the possibilities for limb salvage from complex chronic wounds.

Unilateral remote temperature monitoring to predict future ulceration for the diabetic foot in remission

OBJECTIVE

Daily remote foot temperature monitoring is an evidence-based preventive practice for patients at risk for diabetic foot complications. Unfortunately, the conventional approach requires comparison of temperatures between contralaterally matched anatomy, limiting practice in high-risk cohorts such as patients with a wound to one foot and those with proximal lower extremity amputation (LEA). We developed and assessed a novel approach for monitoring of a single foot for the prevention and early detection of diabetic foot complications. The purpose of this study was to assess the sensitivity, specificity, and lead time associated with unilateral diabetic foot temperature monitoring.

RESEARCH DESIGN AND METHODS

We used comparisons among ipsilateral foot temperatures and between foot temperatures and ambient temperature as a marker of inflammation. We analyzed data collected from a 129-participant longitudinal study to evaluate the predictive accuracy of our approach. To evaluate classification accuracy, we constructed a receiver operator characteristic curve and reported sensitivity, specificity, and lead time for four different monitoring settings.

RESULTS

Using this approach, monitoring a single foot was found to predict 91% of impending non-acute plantar foot ulcers on average 41 days before clinical presentation with a resultant mean 4.2 alerts per participant-year. By adjusting the threshold temperature setting, the specificity could be increased to 78% with corresponding reduced sensitivity of 53%, lead time of 33 days, and 2.2 alerts per participant-year.

CONCLUSIONS

Given the high incidence of subsequent diabetic foot complications to the sound foot in patients with a history of proximal LEA and patients being treated for a wound, practice of daily temperature monitoring of a single foot has the potential to significantly improve outcomes and reduce resource utilization in this challenging high-risk population.

Angiosome perfusion of the foot: An old theory or a new issue?

The angiosome concept of foot perfusion was conceived based on anatomical studies of arterial circulation and used for planning surgical procedures, tissue reconstruction, and amputation. Its application is relevant in diabetic patients with critical limb ischemia and nonhealing foot ulcer or amputation. An understanding of foot angiosome anatomy is useful for predicting healing and planning arterial revascularization. A review of the literature, including the most recent systematic reviews and meta-analyses, indicates improved wound healing is achieved when the angiosome concept is followed. The greatest value of angiosome-based revascularization is in patients with lesion(s) limited to a single angiosome, or to achieve optimal healing of amputation sites. Future research should focus on proper identification of (imaging) modalities to determine the hemodynamic and functional changes before and after revascularization, thus identifying the "real" angiosome and directing optimal therapy.

Role of Extra-articular Tibiotalocalcaneal Arthrodesis and Posterior Approach in Highly Complex Cases

BACKGROUND

Tibiotalocalcaneal (TTC) arthrodesis is a procedure commonly used as salvage surgery for various pathologic processes that compromise the ankle and subtalar joints. It is a reasonably standardized procedure when performed as a primary surgery in advanced stages of TTC arthritis. For such cases, there are several alternative approaches, fixation materials, and bone substitutes that can be used. Most represent valid options with similar results in the literature. However, in highly complex cases requiring TTC arthrodesis, the options for the approach and fixation material can be limited. Understanding the alternative approaches and techniques is of great help to the surgeon when faced with highly complex cases, such as patients with multiple previous operations, lack of bone stock, severe deformities, or compromise of associated soft tissues. In this article, we describe the role of the posterior approach with some technical variation that allows extra-articular arthrodesis in highly complex cases, and we present a series of patients with tibiotalocalcaneal arthrodesis who were operated on using this technique.

METHODS

Retrospective review of all patients who underwent tibiotalocalcaneal arthrodesis via posterior approach between 2008 and 2016. The surgeries were performed by 2 different surgeons with the same technique (posterior approach with sliding graft) but 2 different fixation methods. Radiographs and computed tomographic (CT) studies were reviewed and patient satisfaction was rated using the Coughlin scale. Mean follow-up was 38 months. We identified 20 patients. The mean age was 51.2 years; 11 patients had post-traumatic arthritis whereas the others had other causes of arthritis (inflammatory disease, neurologic deformity, etc).

RESULTS

The arthrodesis was performed using a tibiotalocalcaneal plate in 9 patients and retrograde intramedullary nail in 11 patients. Radiographic fusion was observed at an average of 3.1 months. Four patients had complications and 15 reported good or excellent results after surgery.

CONCLUSION

Our study found a fusion rate comparable to other studies in highly complex cases. There were no operative wound complications. We observed that the posterior approach, with an extra-articular fusion procedure, was a valid option for salvage surgery in highly complex cases that require tibiotalocalcaneal fusion.

LEVEL OF EVIDENCE

Level IV, retrospective case series.

Medial forefoot fillet flap for primary closure of transmetatarsal amputation: A series of four cases

Amputation of the forefoot is a salvage procedure for several forefoot acute or chronic infection. A good, sensate and durable skin cover is important for quicker and better rehabilitation. The use of filleted flaps (or "spare parts technique") has been published in the past as a creative technique. The purpose of this article is to introduce a reproducible, pre-planned, technique that requires less creativity for the use of the "spare parts". The authors describe a case series of 4 patients with deep infection and osteomyelitis of the forefoot, without involvement of the medial skin that underwent two staged procedure for transmetatarsal amputation with medial forefoot fillet flap. The first procedure was amputation of the 4 lesser metatarsal and the wound was left open. After a few days the second operation was done with amputation of the first metatarsal bone and using the filleted medial skin and subcutaneous tissue for closure of the wound. In conclusion the medial fillet flap is an effective method of covering large wounds after partial, lateral forefoot amputation. This method shortens the healing time of the patient, and in hospital stay. The authors recommend using the staged method when dealing with diabetic patients with partial, central and lateral forefoot deep infection and/or necrosis.

Vascular assessment of wound healing: a clinical review

Although macrovascular screening of patients with chronic wounds, particularly in the lower extremities, is accepted as part of clinical practice guidelines, microvascular investigation is less commonly used for a variety of reasons. This can be an issue because most patients with macrovascular disease also develop concomitant microvascular dysfunction. Part of the reason for less comprehensive microvascular screening has been the lack of suitable imaging techniques that can quantify microvascular dysfunction in connection with non-healing chronic wounds. This is changing with the introduction of fluorescence microangiography. The objective of this review is to examine macro- and microvascular disease, the strengths and limitations of the approaches used and to highlight the importance of microvascular angiography in the context of wound healing.

A New Approach for Reconstruction of Diabetic Foot Wounds Using the Angiosome and Supermicrosurgery Concept

BACKGROUND

Major vessels in the diabetic foot are often calcified and inadequate for use as recipient vessels. Thus, a supermicrosurgery technique using small branches or perforators from other collateral vessels with an adequate pulse may be an alternative method. This study evaluated outcome using the supermicrosurgery concept and the risk factors involved.

METHODS

Ninety-five cases of diabetic foot reconstruction were reviewed; the average patient age was 57 years; average follow-up was 43.5 months. Débridement was performed according to the angiosome concept, and reconstruction was performed with perforator flaps using the supermicrosurgery approach. Correlation between total flap loss and 16 preoperative risk factors (age, sex, diabetes mellitus type, smoking, immunosuppression, flap size, hemoglobin A1c, ankle-brachial index, preoperative transcutaneous partial pressure of oxygen, C-reactive protein, computed tomographic angiography, amputation history, peripheral artery disease, American Society of Anesthesiologists physical status, osteomyelitis, and chronic renal failure) were analyzed.

RESULTS

Of 95 cases, nine cases of total loss and 12 of minor complication were noted. Among the risk factors, the odds for failure after peripheral artery disease was 10.99 (p = 0.035), and that associated with a history of amputation was 9.44 (0.0006). Other factors had no correlation with flap loss, including cases with no or one major vessel. Flap survival rate was 90.5 percent, and the overall limb salvage rate was 93.7 percent.

CONCLUSIONS

Despite the high risk of failure related to peripheral artery disease and history of amputation, the supermicrosurgery approach using a recipient vessel with good pulsation regardless of the source can achieve limb salvage. This approach extends the possibility for reconstruction in patients with severe ischemic diabetic foot.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

Innovations in diabetic foot reconstruction using supermicrosurgery

The treatment of diabetic foot ulceration is complex with multiple factors involved, and it may often lead to limb amputation. Hence, a multidisciplinary approach is warranted to cover the spectrum of treatment for diabetic foot, but in complex wounds, surgical treatment is inevitable. Surgery may involve the decision to preserve the limb by reconstruction or to amputate it. Reconstruction involves preserving the limb with secure coverage. Local flaps usually are able to provide sufficient coverage for small or moderate sized wound, but for larger wounds, soft tissue coverage involves flaps that are distantly located from the wound. Reconstruction of distant flap usually involves microsurgery, and now, further innovative methods such as supermicrosurgery have further given complex wounds a better chance to be reconstructed and limbs salvaged. This article reviews the microsurgery involved in reconstruction and introduces the new method of supermicrosurgery.

Direct Revascularization With the Angiosome Concept for Lower Limb Ischemia: A Systematic Review and Meta-Analysis

The angiosome concept provides practical information regarding the vascular anatomy of reconstructive and vascular surgery for the treatment of peripheral arterial occlusive disease and, particularly, critical lower limb ischemia.The aim of the study was to confirm the efficacy of direct revascularization with the angiosome concept (DR) for lower limb ischemia.Complementary manual searches were performed through the Pubmed, Cochrane Library, and EMBASE databases.We searched all randomized and nonrandomized studies (NRSs) comparing DR with indirect revascularization (IR) (without the angiosome concept) for lower limb ischemia. Only 9 nonrandomized controlled retrospective cohort studies were found and included. Trials published in any language were included.Primary endpoints were time to limb amputation and time to wound healing. Data extraction and trial quality assessment were performed by two authors independently. A third author was consulted for disagreements settlement and quality assurance.Five NRSs involving 779 lower limbs revealed that DR significantly improved the overall survival of limbs (hazard ratio [HR] 0.61; 95% confidence interval [CI] = 0.46-0.80; P < 0.001; I = 0%). In addition, DR significantly improved time to wound healing (HR 1.38; 95% CI = 1.13-1.69; P = 0.002; I = 0%, in 5 studies including 605 limbs).All included studies were retrospective comparative studies, and no consensus was obtained in describing wound conditions in the included studies.Our results suggested that treatment of lower limb ischemia using DR is more effective in salvaging limbs and healing wounds than IR is. Additional randomized controlled studies are necessary to confirm these results.

Medial and Lateral Plantar Artery Angiosome Rotational Flaps for Transmetatarsal and Lisfranc Amputation in Patients With Compromised Plantar Tissue

Traditional incision techniques for midfoot amputation might not provide immediate soft tissue coverage of the underlying metatarsal and tarsal bones in the presence of a large plantar soft tissue defect. Patients undergoing transmetatarsal and Lisfranc amputation frequently have compromised plantar tissue in association with neuropathic ulcers, forefoot gangrene, and infection, necessitating wide resection as a part of the amputation procedure. Open amputation will routinely be performed under these circumstances, although secondary healing could be compromised owing to residual bone exposure. Alternatively, the surgeon might elect to perform a more proximal lower extremity amputation, which will allow better soft tissue coverage but compromises function of the lower extremity. A third option for this challenging situation is to modify the plantar flap incision design to incorporate a medial or lateral plantar artery angiosome-based rotational flap, which will provide immediate coverage of the forefoot and midfoot soft tissue defects without excessive shortening of the bone structure. A plantar medial soft tissue defect is treated with the lateral plantar artery angiosome flap, and a plantar lateral defect is treated with the medial plantar artery angiosome flap. Medial and lateral flaps can be combined to cover a central plantar wound defect. Incorporating large rotational flaps requires knowledge of the applicable angiosome anatomy and specific modifications to incision planning and dissection techniques to ensure adequate soft tissue coverage and preservation of the blood supply to the flap. A series of 4 cases with an average follow-up duration of 5.75 years is presented to demonstrate our patient selection criteria, flap design principles, dissection pearls, and surgical staging protocol.

Contemporary assessment of foot perfusion in patients with critical limb ischemia

Significant progress in limb salvage for patients with peripheral arterial disease and critical limb ischemia has occurred in the past 2 decades. Improved patient outcomes have resulted from increased knowledge and understanding of the disease processes, as well as efforts to improve revascularization techniques and enhance patient care after open and endovascular procedures. An imaging modality that is noninvasive, fast, and safe would be a useful tool for clinicians in assessing lower-extremity perfusion when planning interventions. Among the current and emerging regional perfusion imaging modalities are transcutaneous oxygen monitoring, hyperspectral imaging, indocyanine green dye-based fluorescent angiography, nuclear diagnostic imaging, and laser Doppler. These tests endeavor to delineate regional foot perfusion to guide directed revascularization therapy in patients with critical limb ischemia and foot ulceration.

Saving the Limb in Diabetic Patients With Ischemic Foot Lesions Complicated by Acute Infection

Ischemia and infection are the most important factors affecting the prognosis of foot ulcerations in diabetic patients. To improve the outcome of these patients, it is necessary to aggressively treat 2 important pathologies—namely, occlusive arterial disease affecting the tibial and femoral arteries and infection of the ischemic diabetic foot. Each of these 2 conditions may lead to major limb amputation, and the presence of both critical limb ischemia (CLI) and acute deep infection is a major risk factor for lower-extremity amputation. Thus, the management of diabetic foot ulcers requires specific therapeutic approaches that vary significantly depending on whether foot lesions are complicated by infection and/or ischemia. A multidisciplinary team approach is the key to successful treatment of a diabetic foot ulcer: ischemic diabetic foot ulcers complicated by acute deep infection pose serious treatment challenges because high levels of skill, organization, accuracy, and timing of intervention are required to maximize the chances of limb salvage: these complex issues are better managed by a multidisciplinary clinical group.

Diabetic foot ulcers: Part I. Pathophysiology and prevention

Diabetes mellitus is a serious, life-long condition that is the sixth leading cause of death in North America. Dermatologists frequently encounter patients with diabetes mellitus. Up to 25% of patients with diabetes mellitus will develop diabetic foot ulcers. Foot ulcer patients have an increased risk of amputation and increased mortality rate. The high-risk diabetic foot can be identified with a simplified screening, and subsequent foot ulcers can be prevented. Early recognition of the high-risk foot and timely treatment will save legs and improve patients' quality of life. Peripheral arterial disease, neuropathy, deformity, previous amputation, and infection are the main factors contributing to the development of diabetic foot ulcers. Early recognition of the high-risk foot is imperative to decrease the rates of mortality and morbidity. An interprofessional approach (ie, physicians, nurses, and foot care specialists) is often needed to support patients' needs.

Heel Ulcer and Blood Flow

A young female diabetic patient is reported, who presented with a double foot lesion. She presented with a first metatarsal head exposure concomitant with a heel wet gangrene. Magnetic resonance demonstrated osteomyelitis of the rear portion of the calcaneus. Transmetatarsal amputation was performed and a wide debridement was required to remove all gangrenous tissue from the heel wound. The pedal artery was palpable; the posterior tibial pulse was present, but weak.Transcutaneous oximetry (TcPO2) at the dorsum of the foot was TcPO2 = 56 mmHg despite significant oedema. Nevertheless, TcPO2 on the perilesional area of the heel ulcer (TcPO2 = 24mmHg) was suggestive for critical chronic ischemia. At angiographic examination, anterior tibial and peroneal arteries were patent, but the posterior tibial artery that showed severe stenosis then percutaneous angioplasty (PTA) was performed. Just the day after PTA, values of TcPO2 at the perilesional area of the heel ulcer increased to 41 mmHg. Heel osteomyelitis was subsequently treated by partial calcanectomy. The patient was discharged after a 21-day hospital stay. In the treatment of heel ulcers, it is clinically useful to use the angiosomic concept. The majority of the blood supply to the heel is provided by the posterior tibial artery, and only to a small extent by the posterior branch of peroneal artery. If the decrease in blood flow to this region is not detected, and direct flow based on the angiosome concept is not obtained, the healing of a heel ulcer may be delayed or impaired.

Plantar rotational flap technique for panmetatarsal head resection and transmetatarsal amputation: a revision approach for second metatarsal head transfer ulcers in patients with previous partial first ray amputation

Transfer ulcers beneath the second metatarsal head are common after diabetes-related partial first ray amputation. Subsequent osteomyelitis of the second ray can further complicate this difficult situation. We present 2 cases depicting our plantar rotational flap technique for revision surgery involving conversion to either panmetatarsal head resection or transmetatarsal amputation (TMA). These cases are presented to demonstrate our indications, procedure selection criteria, flap technique, operative pearls, and staging protocol. The goals of this surgical approach are to excise and close the plantar ulcer beneath the second metatarsal head, remove any infected bone, allow staged surgery if needed, remove all remaining metatarsal heads to decrease the likelihood of repeat transfer ulcers, preserve the toes when practical, avoid excessive shortening of the foot, avoid multiple longitudinal dorsal incisions, and create a functional and cosmetically appealing foot. The flap is equally suited for either panmetatarsal head resection or TMA. The decision to pursue panmetatarsal head resection versus TMA largely depends on the condition of the remaining toes. Involvement of osteomyelitis in the base of the second proximal phalanx, the soft tissue viability of the remaining toes, the presence of a preoperative digital deformity, and the likelihood that saving the lesser toes will be beneficial from a cosmetic or footwear standpoint are factors we consider when deciding between panmetatarsal head resection and TMA. Retrospective chart review identified prompt healing of the flap in both patients. Neither patient experienced recurrent ulcers or required subsequent surgery within the first 12 months postoperatively.

Descending branch of the perforating branch of the peroneal artery perforator-based island flap for reconstruction of the lateral malleolus with minimal invasion

BACKGROUND

Reconstruction of intractable ulcers on the lateral malleolus is challenging because affected patients suffer various complications. A lateral supramalleolar flap, nourished by the superficial cutaneous branch of the perforating branch of the peroneal artery, has been described as one of the most reliable methods for reconstructing this difficult region. Although the deep descending branch of the perforating branch of the peroneal artery has a tiny cutaneous perforator, a flap based on this perforator has not been described.

METHODS

The vascular anatomy of an island flap based on the descending branch perforator of the perforating branch of the peroneal artery was investigated using 20 cadaver legs. Distances from the lateral malleolus and the external diameters were investigated. Based on the anatomical study results, a perforator-based island flap was developed for clinical use and implemented in five cases.

RESULTS

The anatomical study revealed the descending branch perforator diameter to be smaller than the superficial cutaneous branch diameter, and the location to be considerably closer to the lateral malleolus. All five island flaps used clinically survived without complications.

CONCLUSIONS

A new perforator-based island flap of the descending branch of the perforating branch of the peroneal artery for reconstruction of the lateral malleolus was designed. The territory covered by the flap could be enlarged by including the adjacent angiosome area of the superficial cutaneous branch. This flap elevation technique was uncomplicated and sufficiently straightforward to be used for patients at high risk for complications with extended surgical procedures.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, V.

Rotational flap closure of first and fifth metatarsal head plantar ulcers: adjunctive procedure when performing first or fifth ray amputation

Partial ray amputation is a common treatment of diabetes-related neuropathic ulcers located beneath the metatarsal heads. The standard incision for partial first or fifth ray amputation involves a tennis racket incision, with the proximal arm made mid-line along the respective medial or lateral side of the metatarsal head and neck, creating equal dorsal and plantar flaps. This incision works well when the ulcer is located within the excised soft tissue distal to the incision or when the plantar ulcer is superficial and will heal secondarily once the underlying bone has been removed. This standard first or fifth ray amputation incision does not, however, allow excision and closure of plantar ulcers located beneath the first or fifth metatarsal head. Two cases are presented to demonstrate our surgical protocol for partial first or fifth ray amputation using a local rotational flap to cover plantar metatarsal head ulcers. These cases highlight our patient selection criteria, staging protocol when cellulitis or abscess is present, rotational flap design, surgical technique pearls, and the typical postoperative healing progress.

Near total calcanectomy with rotational flap closure of large decubitus heel ulcerations complicated by calcaneal osteomyelitis

Osteomyelitis is a common late-stage sequela of deep heel ulceration and frequently results in leg amputation, because few options exist to effectively treat this challenging problem. A technique that has been successful at our institution is near total calcanectomy with rotational flap closure of large decubitus heel ulcers complicated by calcaneal osteomyelitis. A case series is presented of 3 patients with differing locations or "zones" of heel decubitus ulceration with acute osteomyelitis. A description of our preferred flap choice, given the zone of the ulceration, is demonstrated, as are the surgical principles for the treatment approach. This procedure is an effective option, provided specific principles are followed to achieve complete wound coverage and minimize pressure points both when in bed and when walking.

An algorithm for limb salvage for diabetic foot ulcers

The treatment of diabetic foot ulceration is complex with multiple considerations often leading to limb amputation. This article presents the usefulness of a multidisciplinary approach along with an algorithm to manage and salvage diabetic foot ulcers from amputation. This algorithm is a step-by-step guide to manage the diabetic foot ulcer and can help one in the selection of patients for limb salvage reconstruction.

Primary infragenicular angioplasty for diabetic neuroischemic foot ulcers following the angiosome distribution: a new paradigm for the vascular interventionist?

The angiosome principle was first described by Jan Taylor in 1987 in the plastic reconstructive surgery field, providing useful information on the vascular anatomy of the human body. Specifically concerning foot and ankle pathology, it may help the clinician to select better vascular access and specific strategies for revascularization. This knowledge may be particularly beneficial when treating diabetic neuroischemic foot wounds associated with particularly aggressive atherosclerotic disease and a poor collateral circulation. The implementation of angiosome-based strategies in diabetic infragenicular vascular reconstruction may afford encouraging wound healing and limb preservation rates using both bypass and endovascular techniques. The minimal invasiveness of these novel strategies enables us to perform more specific and more distal tibial and/or foot arterial reconstructions, in one or multiple targeted vessels. This paper reviews the available literature on this revascularization strategy and focuses on the potential benefit of angiosome-guided primary angioplasty for diabetic ischemic foot ulcers.